Patient adherence with emergency department (ED) referral has not been well studied in Canada, and there are no Canadian studies assessing patient follow-up for evaluation of cardiovascular disease. Our primary objective was to determine the proportion of patients who adhered with an ED referral to a cardiac evaluation and risk assessment (CERA) clinic in Calgary, Alta. Secondary objectives included determining the final diagnoses and outcomes for patients attending CERA appointments. We also assessed the association between adherence and various system and patient factors.

A retrospective review of 385 patients who were referred to CERA from EDs in the study region between June 1, 2004, and Apr. 7, 2005, was performed. Hospital charts and the database at the medical examiner's office were reviewed for patients who did not attend their CERA appointment.

The majority of patients (345/385, 89.6%) followed through with their referral to CERA. No deaths were identified from hospital records or from the medical examiner's office for nonadherent patients. Of the 315 patients who completed their follow-up, 225 (71.4%) were diagnosed with noncardiac or low-risk cardiac disease, whereas 90 (28.6%) were diagnosed with cardiovascular disease. The referring hospital was the only variable significantly associated with adherence with the referral (p = 0.004).

The great majority of patients referred to CERA from Calgary EDs were adherent with the referral. Future studies may identify factors impairing adherence that are amenable to intervention. Implementation of a referral model similar to the one used by CERA may improve adherence with attendance at other outpatient clinics.

The purpose of this study was to evaluate the efficacy, safety and patient satisfaction outcomes of our pharmacist-managed, emergency department (ED)–based outpatient treatment program for venous thromboembolism (VTE) disease.

We conducted a prospective cohort study of all patients who were enrolled in the Vancouver General Hospital (VGH) outpatient VTE treatment program over a 7-year period (1999–2006). Efficacy outcomes include recurrent VTE events at 3 and 6 months following discharge from the program. Safety evaluation included major and minor bleeding complications and the development of thrombocytopenia during the acute phase of therapy. Patient satisfaction was assessed using an 18-question patient satisfaction survey, which was mailed to all patients following discharge from the program.

Overall, 305 patients were included in the study. Of the 260 evaluable patients, 2 patients (0.8%, 95% confidence interval [CI] 0.2–2.7) experienced a recurrent VTE at 3 months and 5 patients (1.9%, 95% CI 0.8–4.4) had a recurrence at 6 months. One patient (0.3%, 95% CI 0.1–1.8) experienced a major bleeding complication. Seven patients (2.3%, 95% CI 1.1–4.7) experienced a minor bleeding complication and no patient developed thrombocytopenia. Overall, 96.1% were comfortable having their condition treated as an outpatient and 85.7% felt it was more convenient to return to hospital daily for medications and assessment than to be admitted to hospital. Finally, 96.9% of respondents were very satisfied or satisfied with the treatment they received in the outpatient program, and 96.1% would enroll again if future treatment was indicated.

Our pharmacist-managed, ED-based outpatient treatment program for VTE disease is safe, effective and achieves a high level of patient satisfaction.

The SimpliRED ᴅ-dimer assay is commonly ordered by emergency physicians for suspected pulmonary embolus or deep venous thrombosis. A pretest probability (PTP) assessment is required for the results of this diagnostic test to be interpreted correctly and applied appropriately. Without this assessment, the physician may misinterpret the test results and proceed to unnecessary diagnostic imaging (DI) or inappropriate discharge. Our objectives were to measure the documentation rate of PTP for emergency department (ED) patients on whom a SimpliRED ᴅ-dimer assay was performed for suspected venous thromboembolism (VTE) and to determine if the clinical management decisions that followed were in keeping with current recommendations.

In this medical record review, we used a random number generator to select 100 charts from all 760 patients who had a SimpliRED ᴅ-dimer performed during a 3-month period at an academic tertiary care centre with 3 EDs. Trained data abstractors, blinded to the study hypothesis, abstracted explicitly defined data from each chart. An independent abstractor assessed the reliability of 15 of the charts that were randomly chosen.

Suspicion of VTE was documented in 97 of the 100 charts. There was no documentation of PTP assessment for 62 of the 97 cases. Ten had a positive ᴅ-dimer but 5 of these had no evidence of subsequent DI. Of the 97 charts reviewed, 24 documented decisions were in discordance with published clinical management recommendations for VTE.

In the majority of ED cases of suspected VTE, PTP assessment was not documented and approximately one-quarter of these documented decisions were in discordance with established recommendations for the given test results. This suggests that PTP assessments are not being conducted in a significant proportion of cases and the diagnostic test results are misinterpreted, applied incorrectly or both.

We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.

We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.

Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).

Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.

In February 2007, the Health Council of Canada, in its third annual report, emphasized the need for pan-Canadian data on our health care system. To date, no studies have examined the strengths and weaknesses of emergency health services (EHS) administrative databases, as perceived by researchers. We undertook a qualitative study to determine, from a researcher's perspective, the strengths and weaknesses of EHS administrative databases. The study also elicited researchers' suggestions to improve these databases.

We conducted taped interviews with 4 Canadian health services researchers. The transcriptions were subsequently examined for common concepts, which were finalized after discussion with all the investigators.

Five common themes emerged from the interviews: clinical detail, data quality, data linkage, data use and population coverage. Data use and data linkages were considered strengths. Clinical detail, data quality and population coverage were considered weaknesses.

The 5 themes that emerged from this study all serve to reinforce the call from the Health Council of Canada for national data on emergency services, which could be readily captured through a national EHS administrative database. We feel that key stakeholders involved in emergency services across Canada should work together to develop a strategy to implement an accurate, clinically detailed, integrated and comprehensive national EHS database.

For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use (length of ED stay and number of revisits) of patients with and without substance problems.

Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003.

Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%–12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%–9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p < 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p < 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p < 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient, p < 0.001).

Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.

There is a paucity of information regarding the usefulness of non-traditional data streams for real-time syndromic surveillance systems. The objective of this paper is to examine the temporal relation between Ontario's emergency department (ED) visits and telephone health line (Telehealth) call volume for respiratory illnesses to test the feasibility of using Ontario's Telehealth system for real-time surveillance.

Retrospective time-series data from the National Ambulatory Care Reporting System (NACRS) and the Telehealth Ontario program from June 1, 2004, to March 31, 2006, were analyzed. The added value of Telehealth Ontario data was determined by comparing it temporally with NACRS data, which uses the International Classification of Diseases (ICD) 10-Canadian Enhancement coding system for discharge diagnoses.

Telehealth Ontario had 216 105 calls for respiratory complaints, while 819 832 ICD-coded complaints from NACRS were identified with a comparable diagnosis of respiratory illness. Telehealth Ontario call volume was heavily weighted for the 0–4 years age group (49%), while the NACRS visits were mainly from those 18–64 years old (44%). The Spearman rank correlation coefficient was calculated to be 0.97, with the time-series analysis also resulting in significant correlations at lags (semi-monthly) 0 and 1, indicating that increases in Telehealth Ontario call volume correlate with increases in NACRS discharge diagnosis data for respiratory illnesses.

Telehealth Ontario call volume fluctuation reflects directly on ED respiratory visit data on a provincial basis. These call complaints are a timely, useful and representative data stream that shows promise for integration into a real-time syndromic surveillance system.

We sought to determine the proportion of Canadian emergency departments (EDs) that have intimate partner violence (IPV) universal screening programs and intervention policies and procedures. Of the EDs with programs, we determined what proportion had made changes in their practices during the past 10 years and since the 2003 Canadian Task Force on Preventive Health Care recommendations.

Using the same sampling methods as a 1994 study, we mailed questionnaires to nurse managers of a stratified, random sample of 250 out of 638 (39%) Canadian EDs and followed up with a series of telephone calls.

Of the 250 EDs initially contacted, 6 were excluded before the surveys were mailed. The response rate was 78.3% (191/244). Sixty-one (31.9%) of the studied EDs reported the existence of IPV policies and procedures. In this group, 26 (42.6%) applied universal screening and 13 (21.3%) implemented their screening policies after the 2003 national recommendations were published. When these results were compared with those of the 1994 study, there was no difference in the proportion of EDs with IPV policies and procedures or in the proportion of EDs that applied universal screening.

Despite increased research into IPV there was no significant change between 1994 and 2004 in the existence of IPV polices or universal screening in Canadian EDs. Policies and procedures that address appropriate responses to patients exposed to IPV should be a priority, with most emphasis directed toward developing effective interventions to which women can be referred.

Consultation is a common and important aspect of emergency department (ED) care. We prospectively examined the consultation rates, the admission rates of consulted patients, the emergency physician (EP) disposition prediction of consulted patients and the difficult consultations rates in 2 tertiary care hospitals.

Attending EPs recorded consultations during 5 randomly selected shifts over an 8-week period using standardized forms. Subsequent computer outcome data were extracted for each patient encounter, as well as demographic data from the ED during days in which there was a study shift.

During 105 clinical shifts, 1930 patients were managed by 21 EPs (median 17 patients per shift; interquartile range 14–23). Overall, at least 1 consultation was requested in 38% of patients. More than one-half of the patients (54.3%) who received a consultation were admitted to the hospital. Consultation proportions were similar between males and females (51% v. 49%, p = 0.03). Consultations occurred more frequently for patients who were older, had higher acuity presentations, arrived during daytime hours or arrived by ambulance. The proportion of agreement between the EP's and consultant's opinion on the need for admission was 89% (κ = 0.77, 95% confidence interval 0.72–0.83). Overall, 92% of patents received 1 consultation. Six percent of the consultations were perceived as “difficult” by the EPs (defined as the EP's subjective impression of difficulties with consultation times, accessibility and availability of consultants, and the interaction with consultants or disposition issues).

Consultation is a common process in the ED. It often results in admission and is predictable based on simple patient factors. Because of perceived difficulty with consultations, strategies to improve the EP consultation process in the ED seem warranted.

The emergency department (ED) environment requires physicians to focus on workflow efficiency (WFE) and manage ED throughput. We sought to determine whether an interactive workshop could be designed and favourably perceived by emergency physicians and residents as a means to improve their self-assessed WFE skills.

The authors designed a 4-station workshop to simulate key components of ED throughput. These included resource management in 1) acute care, 2) minor care, 3) charting and 4) communication skills and patient sign-overs. Anonymous surveys were completed after each workshop using 5-point Likert scales and qualitative responses. Qualitative data encompassed participants' past WFE training experiences and perspectives on the current workshop. Data were analyzed using descriptive statistics. The workshops were administered on 2 separate occasions to different groups of physicians. The first occasion was primarily for residents and the second session was only for practising physicians.

A total of 22 residents and 24 practising physicians participated. Evaluations were completed by 45 of 46 participants. Ratings of “definitely helpful” or “helpful” as noted for each station were received by 37 of 44 respondents for the sign-over and communication station, by 37 of 44 for the minor care station, by 41 of 44 for the acute care station and by 33 of 43 for the effective charting station. Among all participants, 42 of 45 reported that they felt the overall workshop experience was “helpful” or “definitely helpful.”

ED management “flow skills” are valued yet undertaught. A flow workshop designed to improve self-perceived WFE skills yields positive evaluations. Teaching this competency in a workshop setting is both feasible and appreciated by participants. Similar efforts should be considered for inclusion in both graduate and continuing medical education curricula.